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Health Care in the Two Americas: Findings from the Scorecard on State Health System Performance for Low-Income Populations, 2013

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Executive Summary

Ensuring that all people have equal access to high-quality health care to help them live healthy and productive lives is a core goal of a high performance health system. In the United States, however, where you live matters, particularly if you have low income. In many states, there is a wide gulf in access to and quality of care between those with below-average income and the rest of society.


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Scorecard on State Health System Performance for Low-Income Populations, 2013, aims to identify opportunities for states to improve how their health system serves their low-income populations and to provide benchmarks of achievement tied to the top-performing states. Based on its assessment of 30 indicators of access, prevention and quality, potentially avoidable hospital use, and health outcomes, the Scorecard documents sharp disparities among states in each of these areas.

The analysis finds that raising state health system performance to the top benchmark levels would make a critical difference for low-income populations. Between the leading and lagging states, there is often up to a fourfold disparity in performance on indicators of timely access to care, risk for potentially preventable medical complications, lower-quality health care, and premature death, affecting millions of Americans.

If all states could reach the benchmarks set by leading states for more advantaged populations, an estimated 86,000 fewer people would die prematurely, with potential gains of 6.8 million years of life; 750,000 fewer low-income Medicare beneficiaries would be unnecessarily prescribed high-risk medications; and tens of millions of adults and children would receive timely preventive care necessary to lessen the impact of chronic disease and help avoid the need for hospitalization.

Notably, the Scorecard finds that having low income does not have to mean below-average access, quality, or health outcomes. In fact, in the top states, many of the health care benchmarks for low-income populations were better than average and better than those for higher-income or more-educated individuals in the lagging states. With new nationally funded expansions of health insurance and an array of new resources and tools, all states will have a historic opportunity to greatly improve health and health care for vulnerable populations across the country.


Where you live matters: For low-income populations, there are wide differences across states in access, quality and safety, and health outcomes.
Overall, the report finds that there are often two Americas when it comes to health care—divided by geography and income (Exhibit 1). Wide state differences in health care for low-income populations are particularly pronounced in the areas of affordable access to care, preventive care, dental disease, prescription drug safety, potentially preventable hospitalization, and premature death. Nationally, as of 2010–11, over half (55 percent) of the under-65 population with incomes below 200 percent of poverty—nearly 57 million people—were either uninsured, or if insured, were spending a relatively high share of their incomes on medical care. This is sometimes referred to as being "underinsured." The percentage uninsured or underinsured ranged from a low of 36 percent in Massachusetts to over 60 percent in 10 states (Alaska, Colo., Fla., Idaho, Mont., Nev., N.M., Texas, Utah, Wyo.).

Looking across states, a lack of timely, affordable access to care—in particular, primary care—is undermining health outcomes and contributing to higher medical costs:

  • Among low-income adults age 50 or older, just 22 percent to 42 percent received recommended preventive care. This means that even in the leading state, fewer than half of low-income older adults received recommended cancer screenings and vaccines for their age and gender.
  • In 22 states, 30 percent or more of low-income Medicare beneficiaries were prescribed medications that are considered high-risk.
  • Among adults from low-income communities, rates of hospital admissions for respiratory disease or diabetes complications were four times higher in the worst-performing states compared with the top performers. For children in low-income communities, there was a more than eightfold spread between the highest and lowest state rates of hospitalization for asthma.


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The Scorecard also finds wide state differences in health outcomes for low-income and less-educated populations. There was a two- to threefold spread between leading and lagging states in premature death before age 75, infant mortality, smoking, obesity, and dental disease or tooth loss. States with the worst health outcomes on a single indicator tended to do poorly on multiple indicators.

Strikingly, the Scorecard finds much less state variation in health and health care experiences among people with higher incomes. The notable exception was unsafe prescribing: states with high rates of potentially unsafe prescribing were high for both higher- and lower-income Medicare beneficiaries.

Health system performance for low-income populations in leading states is often better than the national average and the high-income populations in other states.
The strong performance of leading states and the more positive experiences of low-income or less-educated populations in those states indicate having a low income does not have to mean worse care experiences or health. For all but six indicators, the experiences of low-income individuals in top-performing states exceeded the national average for all incomes. And for half the indicators, including receipt of medications that put health at risk, potentially preventable hospitalization, infant mortality, smoking, and obesity, the leading states’ rates for their low-income populations was better than those of higher-income populations in other states.

States in the Upper Midwest and Northeast and Hawaii performed best overall for low-income populations.
The six leading states, Hawaii, Wisconsin, Vermont, Minnesota, Massachusetts, and Connecticut, did well across all four performance dimensions (Exhibit 2). Each ranked in the top half of states for the majority of the 30 indicators, particularly those related to access, prevention, and treatment. These leading states had among the lowest rates of uninsured adults, contributing to more positive health care and health outcomes.

At the other end of the spectrum, the Southern and South Central states often lagged other states (Exhibit 2). The 12 states in the lowest quartile performed below average for more than half of the available performance indicators. All these states have high uninsured rates, low rates of preventive care, high rates of potentially avoidable hospital use from complications of disease, and significantly worse health outcomes on multiple indicators.

Notably, states at the bottom have among the highest poverty rates—with nearly half their total population having a low income (under 200% of poverty) or at most a high school education. With such a high share of the state population’s health and well-being at risk, even modest gains would represent substantial gains for the entire state in healthier, more productive lives and potentially lower costs of health care. For such high-poverty states, federal resources to expand coverage and invest in local health systems offer significant new opportunities to improve their population’s health and care experiences.

All states have room to improve. No state was in the top quartile or top half of the range of states for all 30 indicators, and nine of the 10 top-ranked states overall had at least four indicators in the bottom half of the state distribution.

Income-related health care disparities exist within states and across all areas of health system performance.
To establish benchmarks for performance, the Scorecard also compared experiences of low-income or less-educated populations in each state to those with higher income (i.e., above 400% of poverty) or more education (i.e., college degree or higher). Lower-income populations are at increased risk of experiencing worse access, lower-quality care—particularly in outpatient settings—and worse health outcomes compared to those with higher incomes in their home state. Income-related disparities were most pronounced on measures of access, prevention, potentially unsafe prescription medication, and health outcomes.

In all states, low-income adults age 50 or older were less likely to receive preventive care than were higher-income adults, reflecting, in part, the much higher rates of low-income adults who are uninsured. In Kentucky, Idaho, and California, for example, rates of preventive care among higher-income older adults were double the levels reported by those with low incomes.

However, care patterns continue to differ by income even when adults are insured. The Scorecard reveals a pattern across all states, except Hawaii, of low-income Medicare beneficiaries being at greater risk than higher-income beneficiaries for receiving medications generally not recommended because of age or health.

In all states, premature death rates were markedly higher among those with a high school education or less than they were for the college-educated. In 42 states, years of potential life lost before age 75 for college-educated residents age 25 and older were below 5,000 per 100,000 population. However, in all but three states, years lost for those with at most a high school degree were above 10,000 per 100,000.

Health insurance coverage expansions hold promise to begin closing gaps in primary care and prevention. Broader gains will require improvements to health care delivery and a greater focus on population health.
Our findings across states indicate that expanding insurance coverage will begin to close the income and geographic divide. In multiple states, insured low-income individuals report a similar rate of having a usual source of care and receiving recommended preventive care as high-income adults (Exhibit 3).

However, the care experiences of low-income Medicare beneficiaries, all of whom have insurance, show that there are additional opportunities to improve health system performance. For example, the Scorecard finds that one-third of all emergency department (ED) visits by low-income Medicare beneficiaries (i.e., those also receiving Medicaid) are potentially preventable with more accessible primary care. There is a more than twofold variation across states in the potentially avoidable ED use indicator. Efforts to improve health care delivery, particularly primary care, and public health could lower the need for emergency department visits and the risks of receiving an unsafe prescription drug, being admitted or readmitted to hospitals, and dying prematurely or having a disability.

Also required are targeted approaches for pockets of health care need across the country, such as communities with high rates of potentially avoidable hospital admissions among low-income children with asthma and adults with chronic lung disease. Successful intervention in these health care “hot spots” will likely require a combination of enhanced primary care and collaboration with community, social, and public health resources. The same is true for combating higher state rates of smoking, obesity, infant mortality, and premature death in vulnerable populations. Acting early to reduce risks to health from unsafe workplaces, homes, communities, or behaviors would result in a healthier overall population and reduce health care costs over time.

Potential gains from raising the bar and bridging the income divide.

If health care access and care experiences among vulnerable populations in all states were to attain state benchmarks for higher-income or otherwise more-advantaged populations, we might see the following gains:

  • Over 30 million more low-income adults and children would have health insurance—reducing the number of uninsured by more than half.
  • About 34 million fewer low-income individuals would face high out-of-pocket medical costs relative to their annual income and about 21 million fewer low-income adults would go without needed care because of cost.
  • About 11 million additional low-income adults over age 50 would receive timely preventive care, including cancer screenings and immunizations.
  • 750,000 fewer low-income Medicare beneficiaries would receive an unsafe prescription drug.
  • There would be over 300,000 fewer readmissions within 30 days of hospital discharge among low-income Medicare beneficiaries.
  • Fewer people would die prematurely, resulting in about 6.8 million potential years of life to work and participate in communities, or 86,000 fewer deaths each year assuming average life expectancy.
  • 33,000 more infants born to mothers with a high school diploma or less would survive to see their first birthday.
  • Nearly 9 million fewer low-income adults under age 65 would lose six or more teeth because of tooth decay, infection, or gum disease.


Improving health system performance for vulnerable populations no matter where people live is within our grasp as a nation. By investing in improving the health of their most vulnerable, states would improve the overall health and economic well-being of their population. Healthier adults are less expensive to care for and have greater workforce productivity; healthier children are more likely to succeed in school and grow up to continue to participate in the workforce in the future. A healthy population is thus instrumental in maintaining strong local and state economies, as well as the nation’s economic health and well-being.

State and local care system action that leverages federal resources and builds on national initiatives will be critical to the success of efforts to improve access, health care, and health outcomes, particularly for those vulnerable because of low income. The Scorecard ’s findings of high rates of uninsured, low rates of preventive and primary care, variable quality of care, and poor health outcomes for low-income populations underscore the potential gains from focused efforts to:

  • Expand insurance, including Medicaid, and implement policies to hold insurance plans accountable for timely access to provider networks and quality care.
  • Redesign care delivery systems, supported by payment reform, to provide enhanced, patient-centered primary care within care systems that provide effective, safe and coordinated care, with attention to population needs.
  • Hold care delivery systems accountable for population health, including collaboration between health care, public health, and community-based services.
  • Set targets or benchmarks to inform and guide strategic actions to improve.

When looking today at health care access, quality, and outcomes, we see two Americas, sharply defined by geography and income. As federal health reforms take hold and additional resources become available, state governments and local care delivery systems have a historic opportunity to address these inequities. By doing so, we will not only help close the gap, but we will improve the health system’s performance for everyone in the U.S., regardless of geography or income.

Publication Details



C. Schoen, D. C. Radley, P. Riley, J. A. Lippa, J. Berenson, C. Dermody, A. Shih, Health Care in the Two Americas: Findings from the Scorecard on State Health System Performance for Low-Income Populations, 2013, The Commonwealth Fund, September 2013.